Chronic Condition - No Prior Authorization Expiration
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Defines criteria and process for issuing prior authorizations without an expiration date for medications, equipment, or services for members with chronic conditions; applies to Hennepin Health providers and members. Out-of-network providers are excluded.
No material clinical or coverage changes in this revision.
Coverage Criteria for No-Expiration Authorizations
Approval criteria for no-expiration authorization
All of the following must be met for an authorization without expiration to be issued:
Requests submitted by out-of-network providers are not eligible for prior authorizations that omit an expiration date. Providers must be in-network with Hennepin Health to request an authorization without an end date; requests from out-of-network facilities or clinicians will be processed under standard authorization rules and may receive an authorization with a defined expiration.
Coverage and any active authorizations will be stopped as of the date that a drug, device, or service is removed from the market or is deemed unsafe by the FDA or another regulatory authority. This cessation of coverage aligns with Hennepin Health’s contractual obligations and applies regardless of whether an authorization was originally issued without an expiration date.
Coding and Duration Thresholds
Provider Requirements and Authorization Process
Authorization without expiration
A prior authorization may be approved without an expiration date (end date of 12/31/2099) when all listed approval criteria are met.
Quantity limits still apply
All Hennepin Health quantity limits continue to apply when a request does not specify an expiration date; providers must ensure requests conform to existing quantity limit rules.
Request must specify no expiration and medical necessity
The provider must specifically request a prior authorization that does not expire and demonstrate the requested item is medically necessary for a chronic condition expected to last longer than one year with ongoing need.
Ineligibility and stoppage risks
Requests from out-of-network providers are not eligible for no-expiration authorizations; additionally, coverage and authorizations will be stopped if a drug, device, or service is removed from the market or deemed unsafe by FDA or another regulatory authority.
- Out-of-network provider requests cannot receive an authorization without expiration.
- Authorizations will be terminated as of the date the product or service is removed or deemed unsafe by a regulatory authority.
Background
This policy provides a mechanism to support continuity of care for members with chronic health conditions that are expected to last longer than one year. When the approval criteria are met and the provider specifically requests it, a prior authorization may be issued without a conventional end date to avoid frequent renewals for treatments, equipment, or services needed for ongoing management. Standard safeguards remain in place: quantity limits continue to apply and coverage can be stopped if a product is removed from the market or deemed unsafe, and only in-network providers are eligible to receive no-expiration authorizations.
Definitions
Quantity Limits
Site of Care Restrictions
Infusion center/provider eligibility
Out-of-network infusion centers or providers are not eligible to receive authorizations without an expiration date; ensure requests originate from in-network providers.
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